I certify that Informed Consent has been obtained prior to any study procedure.
Item
I certify that Informed Consent has been obtained prior to any study procedure.
boolean
InformedConsentDate
Item
Informed Consent Date
date
Date of birth:
Item
Date of birth:
date
CL Item
Arabic/North African (2)
CL Item
White/Caucasian (3)
CL Item
East & South East Asian (4)
OtherRace
Item
If Other, please specify race
text
Height
Item
Height
integer
BLOOD SAMPLE
Item
Has a blood sample been taken?
boolean
DateBloodSampleTaken
Item
If Yes, please record the date
date
PreviousHepatitisVaccination
Item
Did the subject receive a dose of Hepatitis B vaccine since the last visit
boolean
PreviousHistoryOfHipatitisB
Item
Did the subject develop clinical signs possibly related to hepatitis B since last visit or suffered from hepatitis B?
boolean
Specify
Item
If Yes, please specify below
text
BLOOD SAMPLE
Item
Has a blood sample been taken?
boolean
DateBloodSampleTaken
Item
Please specify the date of blood sample taken
date
PreviousHepatitisBVaccination
Item
Did the subject receive a dose of Hepatitis B vaccine since the last visit
boolean
PreviousHistoryOfHepatitisB
Item
Did the subject develop clinical signs possibly related to hepatitis B since last visit or suffered from hepatitis B?
boolean
Specify
Item
If Yes, please specify
text
BLOOD SAMPLE
Item
Has a blood sample been taken?
boolean
DateBloodSampleTaken
Item
Please specify the date of blood sample taken
date
PreviousHepatitisBVaccination
Item
Did the subject receive a dose of Hepatitis B vaccine since the last visit
boolean
PreviousHistoryOfHepatitisB
Item
Did the subject develop clinical signs possibly related to hepatitis B since last visit or suffered from hepatitis B?
boolean
Specify
Item
If Yes, please specify
text
BLOOD SAMPLE
Item
Has a blood sample been taken?
boolean
DateBloodSampleTaken
Item
Please specify the date of blood sample taken
date
PreviousHepatitisBVaccination
Item
Did the subject receive a dose of Hepatitis B vaccine since the last visit
boolean
PreviousHistoryOfHepatitisB
Item
Did the subject develop clinical signs possibly related to hepatitis B since last visit or suffered from hepatitis B?
boolean
Specify
Item
If Yes, please specify
text
BLOOD SAMPLE
Item
Has a blood sample been taken?
boolean
DateBloodSampleTaken
Item
Please specify the date of blood sample taken
date
PreviousHepatitisBVaccination
Item
Did the subject receive a dose of Hepatitis B vaccine since the last visit
boolean
PreviousHistoryOfHepatitisB
Item
Did the subject develop clinical signs possibly related to hepatitis B since last visit or suffered from hepatitis B?
boolean
Specify
Item
If Yes, please specify
text
FollowUpStudiesParticipation
Item
Would the subject be willing to participate in a follow-up study?
boolean
Item
If No, please specify
text
Code List
If No, please specify
CL Item
Adverse Events, or Serious Adverse Events (1)
AE/SAE
Item
If AE or SAE, please specify
text
OtherSpecify
Item
If Other, please specify
text
Investigator'sConfirmationDate
Item
I confirm that I have reviewed the data in this Case Report Form for this subject. All information entered by myself or my colleagues is, to the best of my knowledge, complete and accurate, as of the date below.
date
Investigator's signature
Item
Investigator's signature
text
Printed Investigator's name
Item
Printed Investigator's name
text
Previous Subject Number
Item
Previous Subject Number
integer
BirthDate
Item
Date of Birth
date
Item
Please document reason for non participation
text
Code List
Please document reason for non participation
CL Item
Subject not eligible (1)
CL Item
Subject lost to follow-up or not reached (2)
CL Item
Subject eligible but not willing to participate due to adverse events, or serious adverse event (3)
CL Item
Subject eligible but not willing to participate due to other reasons (4)
DeathDate
Item
In case of death, please specify date
date
Date of Contact
Item
Date of Contact
date